presentation post-traumatic stress disorder and...

Management of PTSD and TBISaturday, February 25, 2017

Presented by Dr. Joy A. Awoniyi 1

Dr. Joy A. AwoniyiClinical Pharmacist, Mental Health

Miami VA Healthcare [email protected]

Disclosure Statement

I, do not have a vested interest in or affiliation with any corporate organization offering financial support or grant money for this continuing education program, or any affiliation with an organization whose philosophy could potentially bias my presentation.

1

Objectives for Pharmacists

Upon the completion of this CE activity, the pharmacist should be able to…

1. Outline the risk factors, symptoms, and diagnostic criteria of Post‐Traumatic Stress Disorder

2. Summarize the evidence based pharmacological and non‐pharmacological treatments for veterans with PTSD

3. Describe the clinical presentation and management strategies for Traumatic Brain Injury (TBI)

2

Objectives for Technicians

3

Upon the completion of this CE activity, the technician should be able to…

1. List risk factors and symptoms of PTSD and TBI

2. Identify drugs used in the treatment of PTSD and TBI



What is PTSD? (Video)

4

Post‐traumatic Stress Disorder

Description Symptoms

• Mental health disorder developing as a result of trauma or physical harmo Trauma may be emotional or

psychological

o Examples of physical harm

• Stress‐related reactions are common after a traumatic event

• PTSD is characterized by reactions that do not go away over time and disrupt daily life

• Four core clusterso Intrusion

o Avoidance

o Hyperarousal

o Negative changes in cognition and emotions (New with DSM‐5)

• Other common presenting symptomso Chronic pain

o Migraines

o Vague Somatic complaints

5

Pathophysiology• Development is thought to be due to dysregulation of the

hypothalamus‐pituitary‐adrenal (HPA) Axis• Regulates stress response• Below normal concentrations of cortisol cause an elevated stress response• Less cortisol (to reduce stress) causes elevation of the negative feedback response

• Neurobiologic Model• Serotonin – decreased 5HT receptor concentrations• Norepinephrine – increase in NE concentrations

• Downregulation of alpha‐2 receptors• Over‐activity of noradrenergic system

• Gamma aminobutyric acid (GABA)• Dopamine

6

Neurobiologic Model of PTSD

• “Adrenaline rush” or intense arousal that saves lives in combat becomes persistent and maladaptive

• Impaired norepinephrine (NE), dopamine (DA), serotonin (5HT) neurotransmission in CNS

7



Theory of dysregulation of the HPA Axis

8

Traumatic Event – “The Gatekeeper”

• Actual or threatened death, serious injury, or sexual violation

• Exposure may occur in one or more of the following wayso Direct Experienceo Witnessing the event in otherso Learning the event happened to a close family member or friend

• If actual or threatened death: must have been violent or unintentional

• Experiencing repeated or extreme exposure to aversive details of traumatic eventso Does not apply to exposure through television, movies unless work

relatedo Example: First responders collecting human remains

9

Billy Bob

Billy Bob has been bullied and pushed on the ground

everyday since 4th grade because he wears clothes that

don’t fit him. Sometimes he has cuts and bruises from

falling on the ground. He tells his parents he doesn’t want

to go to school or socialize anymore.

10

NODoes this meet

criteria for a PTSD “Traumatic Event”?

Pablo

Pablo was emotionally abused by the director of pharmacy

during his post‐graduate year 1 pharmacy practice residency

training. He cried every night. Upon completion he quit the

pharmacy profession all together to work at a fast food

restaurant

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NODoes this meet criteria for a PTSD “Traumatic Event”?



Betty Sue

Betty Sue was in the army for many years. Her unit was

never in combat, but over the course of 2 years, she saw

several other women in her unit sexually assaulted or

threatened during deployments to Afghanistan.

12

YesDoes this meet criteria for a PTSD “Traumatic Event”?

DSM‐5 CRITERIA FOR DIAGNOSIS OF PTSD

Exposure to a traumatic event

Occurrence of intrusive symptoms

• Recurrent dream, memory, thought, or feeling

• Dissociative reactions (re‐experiencing)

At least one avoidance symptom

•Avoiding activities, thoughts, memories

• Avoiding people, places, situations

At least two changes in cognitions and emotions

• Trouble with recall

• Negative feeling about self or others

• Anhedonia

• Feeling “numb”

At least twohyperarousal symptoms

• Easily startled

• Irritable or angry

• Self‐destructive behavior

• Hypervigilance

Symptoms must…

Last for at least one month

Impair social functioning

Not be caused by another medical condition or the use of a substance

A

B C D E

F

G

H 13

PTSD Timeline

Chronic PTSD

Acute PTSD

Symptoms persist 1‐3 months after the event

Acute Stress Disorder

Symptoms persist 2‐30 days after the event

Acute Stress Reaction

Symptoms persist 0‐2 days after the event

Traumatic Event

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PTSD Subtypes

Dissociative Delayed‐Onset

• Depersonalization

o Feeling as though living a dream were a dream

o Experience of being an outside observer

• De‐realization

o Unreality, distance, or distortion

o Things are not real

• Full criteria not met until 6 months or more after the event

• Usually involve sub‐syndromal symptoms that later progress

• More often seen in military samples

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Epidemiology• Lifetime risk of PTSD at age 75 is 8.7%

o 2005 US 12 month prevalence among adults 3.5%

o Lower estimates in Europe, most Asian, African, and Latin American countries 0.5‐1.0%

• More common in veterans and others whose jobs increase risk of traumatic exposure

• Highest rates among survivors of rape, military combat and captivity, or ethnically or politically motivated internment or genocide

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Our Veteran Population and PTSD

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• PTSD is a growing diagnosis. From 2004 to 2008, the number of individual veterans seeking help for PTSD increased from 274,000 to 442,000.

• Comorbid psychiatric disorders are prevalent in this patient population, including substance abuse, depression and anxiety.

• Patients with PTSD are six times more likely to attempt suicide than the general population.

Risk Factors

Pre‐Trauma

• Prior trauma

• Female gender

• History of adverse childhood experiences

• Prior psychiatric problems

• Low level of education

• Low socioeconomic status

•Minority Race

Peri‐trauma

• Greater severity

• Greater perceived threat

• Feelings of helplessness, unpredictability, or uncontrollability

• Greater Proximity

• Interpersonal trauma (assault)

Post‐trauma

• Low levels of social support

• Ongoing exposure

• Exposure to new trauma

Largest Contributor

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Complications

• Functional Consequenceso High levels of social, occupational and physical disability

o Impairment of social and interpersonal functioning

o Absenteeism from work, lower income and lower educational and occupational success

• Poor physical healtho High levels of medical utilization

o Substantial increase in healthcare costs

• Psychiatric comorbiditieso 80% more likely to meet criteria for at least one other mental disorder

o Substance Abuse

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PTSD Assessments

Tools for recognizing, diagnosing, monitoring PTSD

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Primary Care PTSD Screen (PC‐PTSD)

• In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:

Have had nightmares about it or thought about it when you did not want to?

Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

Were constantly on guard, watchful, or easily startled? Felt numb or detached from others, activities, or your surroundings?

• Each Symptom is assigned 1 point• If patient endorses any of the above symptoms, this should be

considered a positive screen

21

PTSD Checklist (PCL‐5) • 20 item self‐reported measure of symptoms

• Can be administered by any health clinician or given to a patient in a waiting room (5‐10 minutes)

• Purposeo Screening for PTSD

o Monitors symptom change during and after treatment

o Provisional PTSD Diagnosis

• Updated with DSM‐5 and not compatible with previous PCL versions

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PTSD Checklist (PCL‐5) • Provisional Diagnosis

o Made if patient endorses symptoms based on scores in symptom clusters

o Also made with a summative score of 33 or higher

• May use a lower score if screening

• May use a higher score if diagnosing

• Measuring change to monitor your patient’s progress with PTSD treatment o Evidence suggests that 5‐10 point change represents statistically significant

change

o A 10‐20 point change represents a clinically significant change.

o Use 5 points as a minimum threshold for determining whether an individuals has responded to treatment

o Use 10 points as a minimum threshold for improvement is clinically meaningful

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PCL‐5 Assessment CaseJD is a 33 y0 AA female who was referred to the Clinical Pharmacist for depression management. She was started on escitalopram and referred to the pharmacist for follow‐up evaluation, medication titration and management. During her initial assessments, JD reported that during around her deployment to Iraq in February 2004 she had a series of traumatic events that included exposure to mortars and IED.

The pharmacist administered the PCL assessment.Report how often you’ve been bothered by the problems mentioned. Base your answers on the problems that started or got worse after the event

0= not at all1 = a little bit2 = moderately3 = quite a bit4 = Extremely

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In the past month how often have you been bothered by…

Cluster B: Intrusion Criteria B: At least 1 symptom for diagnosis

ScoreMax: 20

1. Repeated, disturbing, and unwanted memories of the experience? 42. Repeated, disturbing dreams of the experience? 33. Suddenly feeling or acting as if the experience were actually happening again (as if you were actually back there reliving it)?

1

4. Feeling very upset when something reminded you of the experience? 35. Having strong physical reactions when something reminded you of the experience (for example, heart pounding, trouble breathing, sweating)?

0

Cluster B Total: 11Cluster C: Avoidance Criteria C: At least 1 symptom for diagnosis

ScoreMax: 8

6. Avoiding memories, thoughts, or feelings related to the experience? 07. Avoiding external reminders of the experience (for example, people, places, conversations, activities, objects, or situations)? 0

Cluster C Total: 025


Cluster D: Changes in cognition or emotions Criteria D: At least 2 score of 2 for diagnosis

ScoreMax:

8. Trouble remembering important parts of the experience (for some reason besides a head injury or alcohol or drug use)?

0

9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

2

10. Blaming yourself or someone else (who didn’t directly cause the event or actually harm you) for the experience or what happened after it?

0

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

0

12. Loss of interest in activities that you used to enjoy? 113. Feeling distant or cut off from other people? 314. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

1

Cluster D Total: 7

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Cluster E: Hyperarousal Criteria D: At least 2 symptoms for diagnosis

ScoreMax:

15. Feeling irritable or angry or acting aggressively? 116. Taking too many risks or doing things that could cause you harm? 017. Being “super‐alert” or watchful or on guard? 418. Feeling jumpy or easily startled? 319. Having difficulty concentrating? 420. Trouble falling or staying asleep? 4

Cluster E Total: 16Sum of All Clusters: 34

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Based on JD’s Assessment, which statement is not correct?A. A provisional diagnosis 0f PTSD can be madeB. More information will need to be obtained to diagnose JD with PTSDC. The pharmacist should not have performed the PCLD. JD should be counseled about her sleep



PCL Assessment Case Continued

When should the pharmacist follow‐up to see if there has been a change in symptoms?A. 7 days

B. 14 days

C. 30 days

D. 90 days

What PCL score would indicate the patient is responding to the treatment?

What PCL score would indicate that the improvement in symptoms is clinically meaningful?

What additional question(s) must we ask to asses if JD meets DSM‐V Criteria for PTSD?A. Have you used any drugs or

alcohol within the past month?

B. Do your symptoms make it difficult for you to get along with others or take care of things at home?

C. Do you have any other medical problems?

D. All of the above

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JD refused referral to a specialist for PTSD evaluation and treatment

34‐5 = 29 or less

34‐10 = 24 or less

Clinician Administered PTSD Scale(CAPS‐5)• Gold Standard for diagnosis

• Clinician‐administered 30 item questionnaire often used in studies (35‐45 minutes)

• Considers frequency and intensity of DSM‐5 specified symptoms

• Includes a Life event checklist (LEC) to assess if patient meets Criteria A

• Assesses dissociative symptoms

• Available in 3 versionso Past week –Monitors change n symptoms

overtime

o Past month – For diagnosing current PTSD

o Past month/Worst Month‐ any month in patients lifetime

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Maintaining Validity of Standardized Assessments

• Potential issueso Under‐reporting

o Over‐reporting

o Current mental status (intoxication, dementia)

• Assess and minimize threats to validityo Consider Veterans own view of their mental health and the assessment

o Ask for clarification; examples if necessary

o Read through other chart notes and diagnosis

o Consider benefits and risks for low and high scores

o Building rapport

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Medical Assessment

• Obtain full medical history, including injuries or past psychological history

• Medication listo OTC medications

o Herbals

• Assess substance use or co‐occurring disorders

• Physical Exam, laboratory tests

• Mental Status Examination

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Functional Assessments

Work

School

Marital/ Family

RelationshipRecreation

Housing

Legal

Financial Community Involvement

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Determine Optimal Setting for Management

• Educate patient and familyo Nature of symptoms

o Coping mechanisms

o Build motivation to participate or persist in treatment

• Integrated treatment to coordinate continued care for chronic co‐occurring disorderso Primary Care Provider

o Patient and Family

o Behavioral Healthcare

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Evidence‐based Treatments for PTSD

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VA/DoD 2010 PTSD Clinical Practice Guidelines

VA/DoD 2010 Guidelines Management Overview

Process Treatment Options

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Step E

Follow‐up as Indicated

Step D

Reassess

Step C

Manage Specific Symptoms as indicated

Step B

Initiate Adjunctive therapy as indicated

Step A

Initiate Treatment Using Effective Interventions for PTSD

• First‐line treatment optionso Pharmacotherapyo Psychotherapy

• Adjunctive treatments• Somatic and Alternative

interventionso Complimentary Alternative

Medicine (CAM) consistent with patient belief systems

o Acupuncture

• Symptom‐specific management interventionso Insomniao Chronic Paino Substance Use/Dependence



“Stepped Care Treatment of PTSD”

Initial

Reassess at 2‐4 weeks

•Psychotherapy or

•Medication: SSRI, SNRI

Step I

4‐6 week assessment

•Asses and address non‐adherence

•Switch to another SSRI, SNRI and/or

•Psychotherapy

Step 2

8‐12 week Assessment

•Add psychotherapy and/or

•Switch to mirtazapine

Step 3

Reassess at >12 weeks

•Switch to alternative step II or phenelizine, nefazodone, TCA

•Add Psychotherapy

At any time• Add prazosin for sleep/nightmares• Consider referral to specialty care

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Pharmacotherapy should be considered as one aspect of a broader management plan for

PTSD. SSRIs and the SNRI venlafaxine should be used as first line psychotropics

Pharmacotherapy

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1st Line Antidepressants

• The SSRIs paroxetine, sertraline and fluoxetinehave the largest collection of evidence showing their efficacy in this population.1

• Evidence supports SNRI venlafaxine. Remission rates at 24 weeks were reported to be 51% versus 38% for placebo (p=0.01, NNT = 8).2

Cochrane Review: 11 week reported response1

0

5

10

15

20

25

% resp

onse > place

bo

1) Stein DJ, et al.. ChochraneDatabase of sys rev 2009:CD002795. 2)Davidson J, et al. Arch Gen Psychiatry. 2006; 63: 1158‐1165. 38

Other Antidepressants

39

• Clinical trials have shown promising results for mirtazapine, amitriptyline, imipramine, phenelzine, duloxetine and nefazodoneo Limited by small sample sizes and open label design or medication

safety/side effect profiles

o These antidepressants should be reserved for patients who have failed SSRI or SNRI monotherapy

• Monitoring for side effects and drug interactions is important



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Generic(Brand) Initial Dose

Max per day

Geriatric Dose Range (mg)

RenalImpairment

Hepatic Impairment

SSRI

Fluoxetine(Prozac)

20 mg daily 80 mg 5‐40 daily No change Dose 50%

Paroxetine(Paxil)

20 mg daily 50 mg 10‐40 daily CrCl <30: Max 40mg

Max 40mg per day

Sertraline(Zoloft)

50 mg daily 200 mg 25‐150 daily No change Dose 50%

SNRI

Venlafaxine IR(Effexor)

37.5 mg BID 225 mg (2‐3 doses)

25‐225 daily

CrCl 10‐70: dose 50%

Dose 50%Venlafaxine ER(Effexor ER)

75 mg daily 225 mg 37.5‐225 daily

OTHER

Mirtazapine(Remeron)

15 mg qHS 45 mg 7.5‐45 daily CrCl <40: use with caution

Titrate slowly

Nefazodone(Serzone)

100 mg BID 300 mg BID

300‐600 BID No change Avoid

Phenelzine(Nardil)

15 mg TID 60‐90 mg then dose

15‐60(TID/QID)

Lower dose may be needed

Avoid

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Comparisons of Antidepressants used PTSD1

Drug Dosage Forms2

GIType3 AC SD WD DI OD PC

Other FDAUses4 Notes5

SSRI

FluoxetineCap, Tab, Sol

N C BN, OCD,PMDD

• No need to taper at discontinuation• No MAOI for 5 weeks after discontinuation

ParoxetineCap, Tab, Sus N

D GAD, MVS, OCD, PD, PMDD, SAD

• Discontinuation syndrome, sexual dysfunction• Dose at bedtime unless insomnia• Changes in weight and appetite• Preferred in breastfeeding mothers

SertralineTab, Sol

N,D C OCD, PD, PMDDSAD

• May cause diarrhea with quick dose increase• Absorption increased with food• Preferred in breastfeeding mothers

SNRI

DuloxetineCap

N C DPNP, FBM, GAD,CMP

• Monitor liver function• Must be swallowed whole• Clearance increased in smokers

Venlafaxine ERTab, Cap

N

CGAD, PD,SAD

• Dose related incr. in c b/p ; control before starting• Dose‐dependent anorectic effects and weight loss

reported• May increase cholesterol levels

OTHER

MirtazapineTab, Odt

CNone

• Increased appetite and weight gain• May increase triglycerides and cholesterol levels

NefazodoneTab

C,N C

None

• sexual dysfunction• Hepatotoxicity; discontinued in Canada• Reduce alprazolam dose by 50%, triazolam dose by

75% if given together

PhenelzineTab

C Cnone

• Monitor blood pressure• Requires low‐tyramine diet (MAOI)

1. GI= Gastrointestinal side effects; AC= anticholinergic side effects; SD= Sedation; WD=Withdrawal; DI= Drug Interactions; OD=overdose risk; PC= Pregnancy Category; 2. Cap=Capsule; Tab= Tablet; Sol = Solution; Sus= Suspension; Odt= Orally disintegrating tablet3. C= Constipation; D= Diarrhea; N=nausea/vomiting4. BN=Bulimia Nervosa; CMP=Chronic Musculoskeletal Pain; DPNP=Diabetic Peripheral Neuropathic Pain; FBM=Fibromyalgia; GAD=Generalized Anxiety Disorder; MVS=Menopausal

Vasomotor Symptoms; OCD=Obsessive Compulsive Disorder; PD=Panic Disorder; PMDD=Premenstrual dysphoric disorder ; SAD=Social Phobia/Social Anxiety Disorder;5. MAOI=monoamine oxidase inhibitors; = highest incidence compared to other meds; =lowest incidence compared to other meds

less common intermediate more common

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Comparisons of Antidepressants used PTSD1 (cont’d)

Drug Dosage Forms2

GIType3 AC SD WD DI OD PC

Other FDAUses4 Notes5

TCA

AmitriptylineTab

C C None • Smokers: higher doses may be required • Blood levels may be monitored for toxicity• Avoid use in elderly patients• Fatal in overdose• Contraindicated if MI within 2 weeks

ImipramineCap, Tab C

D None • Blood levels may be monitored for toxicity• Avoid use in elderly patients• Fatal in overdose• Contraindicated if MI within 2 weeks

1. GI= Gastrointestinal side effects; AC= anticholinergic side effects; SD= Sedation; WD=Withdrawal; DI= Drug Interactions; OD=overdose risk; PC= Pregnancy Category; 2. Cap=Capsule; Tab= Tablet; Sol = Solution; Sus= Suspension; Odt= Orally disintegrating tablet3. C= Constipation; D= Diarrhea; N=nausea/vomiting4. BN=Bulimia Nervosa; CMP=Chronic Musculoskeletal Pain; DPNP=Diabetic Peripheral Neuropathic Pain; FBM=Fibromyalgia; GAD=Generalized Anxiety Disorder;

MVS=Menopausal Vasomotor Symptoms; OCD=Obsessive Compulsive Disorder; PD=Panic Disorder; PMDD=Premenstrual dysphoric disorder ; SAD=Social Phobia/Social Anxiety Disorder;

5. MAOI=monoamine oxidase inhibitors; = highest incidence compared to other meds; =lowest incidence compared to other meds

less common intermediate more common

ANTIDEPRESSANT BLACK BOX WARNING

May increase the risk of suicidality in young adults 18‐24 years old in the first 1‐2 months of treatment

Short term studies did not show increase in risk of suicidality with antidepressants beyond age 24

There was a reduction in risk with antidepressants compared to placebo in adults age 65 and older

Prazosin

• Approximately 70% of patients with PTSD suffer from disrupted sleep patterns including nightmares and frequent awakenings.

• A generic lipid‐soluble alpha‐1 adrenoreceptor (AR) antagonist introduced in 1973 as “Minipress” for treatment of hypertension

• Prazosin doses average 9‐13 mg nightly in most studies Titration to 20 mg or more in some vets for bedtime dosing

BID dosing currently being studied for daytime hyperarousalsymptoms

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Prazosin is a reasonable option for treatment of trauma nightmares in Veterans with PTSD.



Off‐label use of Prazosin

• Dosing:o Start at 1mg PO qHS

o Maintenance 2‐15 mg per day – any dose increases should be given at bedtime

o If therapy interrupted for 3 days, restart titration

• Pregnancy Category C

• Side Effectso Dizziness

o Orthostatic Hypotension, syncope

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• PTSD Indicationso PTSD‐related nightmares and

sleep disruption. B Level Recommendation (Fair Evidence)

o For global symptoms. C Level Recommendation (Fair evidence but no general recommendation)

• Other Indicationso Hypertension (FDA Approved)

o BPH

o Raynaud Phenomenon

Two Prazosin RCTs in Vietnam Veterans with PTSD: CAPS Recurrent Distressing Dreams (“Nightmares”)

Raskind MA, et al.. Biol Psychiatry. 2007; 61: 928‐934.Raskind MA, et al. Am J Psychiatry. 2003; 160: 371‐373 45

• 237 veterans (mean age 54) prescribed prazosin (n=62) or quetiapine (n=175) for PTSD nighttime symptoms

• Short‐term effectiveness: Did % improved within 6 months differ between drugs?

• Long‐term effectiveness: Did % treatment continued until October 2008 endpoint differ between drugs? (3 to 6 years of medication continuity)

Baseline(2002‐2005)

6 Months End Study(2008)

Prazosin 1.4 mg 3.2 mg 6.3 mg

Quetiapine 41 mg 101 mg 135 mg

Chart Review: Prazosin vs QuetiapineByers MG, et al.. J Clin Psychopharmacol. 2010; 30: 225‐229.

46 47

0

10

20

30

40

50

60

70

Prece

nt of Patients

Prazosin

Quetiapine

Effectiveness Reason for discontinuation ADR leading to discontinuation

•Similar short‐term (<6mo) effectiveness • Vets were significantly more likely to continue prazosin therapy long‐term

Byers MG, et al.. J Clin Psychopharmacol. 2010; 30: 225‐229.

Chart Review: Prazosin vs QuetiapineN=237

p<0.001

p=0.003

p<0.008

p<0.001

p=0.014



The routine use of benzodiazepines is not recommended in patients with PTSD and discontinuation should be considered

Benzodiazepines

Benzodiazepines

49

• Risks outweigh benefits for chronic use in PTSD

• There is no evidence that benzodiazepines reduce the core symptoms of PTSD or work for PTSD‐related sleep dysfunction

• Withdrawal of benzodiazepines is difficult in this population and can result in increased anxiety, sleep disturbances, rage, hyper‐alertness, increased nightmares and intrusive thoughts

o Withdrawal has been documented after as little as 5 weeks of therapy

Departments of Veterans Affairs and Defense. (2010). VA/DoD Clinical practice guideline for the management of post‐traumatic stress.

There is limited evidence for the use of atypical antipsychotics in PTSD and they cannot be recommended at this

time

Antipsychotics

Risperidone vs. Placebo in Veterans with Chronic Post‐Traumatic Stress Disorder

51

0

10

20

30

40

50

60

70

80

90

CAPS Total Re‐experiencing Avoidance Hyperarousal CGI‐Patient CGI‐Observer

Baseline

Risperidone

Placebo

p = 0.005p= 0.004

No difference was found at 6 months between adjunctive risperidone (n=133) and placebo (n= 134)

Krystal JH, Rosenheck RA, Cramer JA. JAMA. 2011; 306: 493‐502.



Other MedicationsAgent/Class Recommendation Details Strength Rating

Benzodiazepines • There is evidence to suggest against the use of benzodiazepines

• Strongly recommend against the use for prevention of acute stress disorder or the treatment of PTSD

D

Antipsychotics • The evidence does not support the use of atypical antipsychotics as monotherapy for PTSD

• Recommend against the use of Risperidone as an adjunctive medication

• There is insufficient evidence to recommend for or against typical antipsychotics for adjunct or monotherapy for PTSD

I

D for risperidone

Anticonvulsants • The evidence does not support the use of anticonvulsants as monotherapy for PTSD

D, I

Bupropion, Trazodone

There is insufficient evidence to recommend the use of these medications as monotherapy in PTSDTrazodone may be useful as adjunctive therapy in PTSD

I

D = Ineffective or Harmful; I = Insufficient Evidence/Unknown benefit 52

Veterans diagnosed with PTSD should be offered trauma‐focused psychotherapeutic interventions

Non‐Pharmacologic Therapies

53

Evidence‐based Psychotherapies

54

• Should be considered 1st line for treatment of PTSD

o Best for patients who are willing to address his or her PTSD symptoms and participate in therapy

• Are effective for complex patients

o Co‐morbid personality disorders, SUD, TBI, etc.

• Effects are long lasting

o Significant decrease in PTSD symptoms lasting up to 5 years after treatment

55

Psychotherapy Interventions for the Treatment of PTSD

Classification Process

Cognitive‐based Emphasize cognitive restructuring; relaxation techniques; discussion/narration of the traumatic event

Exposure‐based Psychoeducation; imaginal or narrative exposure; in‐vivo exposure; processing of thoughts and emotion

Stress Inoculation Coping/anxiety management skills (deep muscle relaxation, breathing control, assertiveness, thought stopping, positive thinking, self‐talk); in‐vivo exposure

Eye Movement Desensitization and Reprocessing (EMDR)

Access disturbing image with associated body sensation; relaxation/self‐monitoring techniques, alternating eye movements



Cognitive Processing Therapy (CPT)

• Goal: Improve mood and behaviors by modifying irrational or dysfunctional thoughts, beliefs and expectations

• Treatment courseo 12 sessions, 1‐ 2 sessions/week

o 50‐120 minutes/session

o Homework between sessions

o Can be performed in individual or group formats

• Most effective for Veterans who are willing to address their PTSD symptoms and participate in therapy

Foa et.al. Effective treatment for PTSD practice guidelines from the International Society for Traumatic Stress Studies, 2nd edition. Guideline 4: Cognitive‐Behavioral Therapy for adults. www.istss.org. Accessed 2/25/11.

56

A Comparison of OEF/OIF and Vietnam Veterans Receiving Cognitive Processing

Therapy

57

0

10

20

30

40

50

60

70

80

Vietnam veterans OEF/OIF veterans

CAPS Sco

re

Pretreatment

Posttreatment

N =101

Only 41% of the OEF/OIF and 60% of the Vietnam veterans met post‐treatment diagnostic criteria for PTSD. OEF=operation enduring freedom, OIF =operation Iraqi freedom

Chard KM. Journal of Traumatic Stress 2010;23:25‐32.

Cognitive Processing Therapy (Video)

58

Prolonged Exposure (PE)

59

• Goal: Reduce distress, fear and arousal through repeated exposure to trauma‐related thoughts, feelings and situations

• Treatment courseo 8‐15 sessions, 1‐2 sessions/week

o 90 minutes/session

o Homework between sessions

• Patients may temporarily experience an increase in their level of distress, however there is no data indicating an increase in hospitalizations secondary to trauma‐focused psychotherapy



Prolonged Exposure (Video)

60

Patient Counseling

Important education for patients treated for PTSD

61

General Education

• Information provided shouldo Normalize common reactions to trauma

o Enhance self‐care

o Improve coping

o Facilitate recognition of significant problems

o Inform regarding access to service

• Methods of Education deliveryo Public Media

o Community education activities

o Written materials

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Antidepressant patient counselingBLEEDING RISK

•Avoid aspirin or NSAIDs unless prescribed due to increased risk of bleeding

• Report signs of new or unusual bleeding

BEHAVIOR CHANGES

• Report any worsening of mood, suicidal ideation, or unusual changes in behavior

SIDE EFFECTS

• Side effects usually occur before symptoms improve but usually go away

• Serotonin syndrome is rare but serious. Know the signs and report to the ER immediately

ADHERENCE

Improvement of symptoms may not occur for 2‐6 weeks

of taking medication consistently

Do not stop taking medications abruptly. May

cause discontinuation syndrome

63



Serotonin Syndrome

Signs and SymptomsOther medications that

increase serotonin

64

• Marked by three groups of symptomso Mental status changes ‐

Agitation, anxiety, confusion, restlessness, excitement

o Neuromuscular hyperactivity –Tremors, muscle twitches or spasms

o Autonomic hyperactivity – High blood pressure, sweating, flushing, vomiting, diarrhea

• Usually occurs with drug combinations

• Antibiotico Linezolid (Zyvox®)

• Other Rx antidepressants

• Pain Medicationso Tramadol (Ultram®)

o Sumatriptan (Imitrex®)

• OTC medicationso Dextromethorphan (in Tylenol

DM® and Mucinex DM®)

o Ginseng

o St. John’s Wort

For More Information…

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Traumatic Brain InjuryBackground

Definitions, Symptoms, and Diagnosis

66VA/DoD Clinical Practice Guideline

Epidemiology

• Every year…

o 1.7 million people sustain TBI in the United States

o 2.2 million ER visits50,000 deaths due to TBI

• Since 2000 over 294,000 service members have sustained a TBI

• Co‐occurrence of PTSD and mild TBI is 48%

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Traumatic Brain Injury• A traumatically induced structural injury and/or

physiological disruption of brain function as a result of an external force

• Indicated by at least one clinical sign immediately following the evento Post‐traumatic Amnesia

o Alteration of mental state at the time of injury

o Neurological deficits

o Intracranial lesion

• Classified as mild, moderate or severe ‐ over 80% of diagnosed TBIs are mild

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External Forces The head being struck by an object

The head striking an object

Acceleration/deceleration of brain movement without direct trauma to the head

Penetration of the brain by a foreign body

Forces generated from blasts, explosions, etc.

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Motor Vehicle

Accident, 13.5%

Falls, 43.5%

Assault, 11.6%

Struck by/against,

18.1%

All Other, 7.7%

Unknown, 5.6%

Comparison of TBI‐related ED Visits TBI by Injury Mechanism – US 2006‐20101

Diagnosis• Clinical and relies predominately on patient history

• Evidence does not support the use of any lab, imaging or physiological tests to establish a definitive diagnosis

• Evaluate individuals who present with symptoms or complaints potentially related to the injury

• Preferred communication of the diagnosis is “history of TBI” or “concussion”

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Screening

Traumatic Brain Injury‐4 (TBI‐4)

• Have you ever been hospitalized or treated in an emergency room following a head or neck injury?

• Have you ever been knocked out or unconscious following an accident or injury?

• Have you ever injured your head or neck in a car accident or from some other moving vehicle accident?

• Have you ever injured your head or neck in a fight or fall?

71Brenner et al. 2013



Post‐mTBI related SymptomsPhysical

Headache

Fatigue

Balance disorders

Seizures

Numbness/tingling

Cognitive

Inability to concentrate

Memory problems

Slowing of Processing

Judgement impairment

Behavioral/Emotional

Depression

Anxiety

Agitation/Irritability

Aggression

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Any of the above symptoms may develop within 30 days of injury

Classification of TBI Severity

If a patient meets criteria in more than one category of severity, the higher severity level is assigned

Criteria Mild Moderate Severe

Structural Imaging Normal Normal or Abnormal

Loss of Consciousness 0‐30 min >30 min and <24 hrs

24 hrs or more

Alteration of consciousness/mentalstate

Up to 24 hours

>24 hours; severity based on other criteria

Post‐traumatic Amnesia 0‐1 day >1 and <7 days 7 days or more

Glasgow Coma Scale (best within 24 hours)

13‐15 9‐12 <9

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Clinical Symptom Management mTBI

“There are no specific FDA approved pharmaceutical agents for the treatment of any post‐concussive neurological or psychiatric symptoms emerging after mTBI. Experts in the field recommend using published CPGs for other neuropsychiatric conditions as a reference, as well as the general guidance from the fields of

neuropsychiatry and behavioral neurology”

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Co‐occuring Conditions• Individuals should be assessed in the primary care

setting and screening instruments should be used

• Identify patients who may require further assessment or referral

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HeadachesDizziness and Disequilibrium

Visual Symptoms

Fatigue

Sleep Disturbances

Cognitive Symptoms

Persistent pain

Hearing Difficulties/ Tinnitis

Appetite Changes

Nausea Numbness



General Considerations for Medications

• Medications to avoido Seizure threshold lowering

o Medications that cause confusion

• Rule out other factors before prescribing

• Titrate to maximal tolerated dose before discontinuing

• Assess regularly for side effects and drug‐drug interactions

• Limit quantities with high risk for suicide

• Educate patients to avoid alcohol

• Minimize use of caffeine and “energy” over‐the‐counter and herbal products

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Post‐Traumatic Headaches

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Posttraumatic Headaches

• Secondary headache disorders that start within 7 days of a head trauma

o Acute – Resolves within 3 months

o Chronic – Persisting longer than 3 months

• Occur acutely in 90% of individuals who sustain a concussion

• Most common patterns of posttraumatic headache

o Tension type

o Migraine

o Mixed migraine and tension type

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Tension‐like or Migraine‐like

Feature Tension Migraine

Pain Intensity Mild to moderate Severe or debilitating

Pain Character Dull, aching, band‐like Throbbing or sharp/stabbing

Duration Usually less than 4 hours Can last longer than 4 hours

Phono‐or photophobia

Less common; usually one or the other

One or both usually present

Functionality Usually able to carry out routine activities

Loss of functionality is common, worsened with physical exertion

Nausea/Malaise Not present Usually Present

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Pharmacologic Treatment of Post‐traumatic Headaches

Tension Migraines

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• Prescription strength NSAIDs

• Combination medications (APAP, ASA, caffeine, and sedatives)o Limit to 2 days per week to

avoid side effects and dependency

• OTC are often used by patients prior to being seen

• Abortive Medicationso NSAIDS

o 5HT Receptor antagonists

o Combination medications

o Antiemetic

• Prophylactic Medicationso Anticonvulsants

o Beta‐blockers

o Alpha‐blockers

o TCAs

o Supplements (Magnesium, riboflavin)

Abortive Migraine MedicationsAgents Comments

NSAIDS • Ibuprofen • Ketorolac IM inj• Naproxen

• Limit use to prevent rebound headaches• Bleeding‐related risks

5HT Receptor Agonists

• Rizatriptan• Sumatriptan (PO, IN, SC, TD)• Zolmitriptan

• Caution if hx of cardiac events• Risk for serotonin syndrome• Limit use to prevent rebound headaches

Rx Combos

• Butalbital/APAP/Caffeine• Butalbital/ASA/Caffeine• APAP/Isometheptene/

Dichloralphenazone

• Use if 5HT agonists are contraindicated• Monitor APAP consumption• Assess bleeding risk with ASA

OTC • APAP• ASA• APAP/ASA/Caffeine

• Risk of tinnitus with ASA containing meds• Limit use to prevent rebound headaches

Antiemetic Agents

ProchlorperazinePromethazine

• EPS with long term use• May cause drowsiness and constipation

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Prophylactic Migraine Medications

Agents Comments

Anticonvulsants • Gabapentin• Topiramate• Divalproex NA

• Gabapentin with dual benefits• Monitor for drug interactions, renal and

hepatic function• Topiramate may cause weight loss

Beta‐blocker • Propranolol • May cause fatigue, exercise intolerance. depression

• May cause abnormal dreams

Alpha‐blocker • Prazosin • Titrate slowly to avoid• Benefit for co‐occurring PTSD

TricyclicAntidepressants

• Amitriptyline• Desimpramine• Nortriptyline

• Monitor for suicidality• Drug interactions and side effects• Avoid abrupt discontinuation

Vitamins/Supplements

• Magnesium Oxide• Vitamin B2

• MgSO4 should be separated from other meds

• B2 may discolor urine. 82

• Migraine headaches occur more than once a week• Headache attacks are disabling despite aggressive acute interventions• Headaches compromise work attendance, societal integration, or daily life

Sleep Disturbances

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Sleep Disturbances• Occurs in ~30% of patients following mTBI

• Types of sleep disturbanceo Difficulty falling asleep or staying asleepo Delayed sleep phase syndromeo Irregular sleep/wake patterns

• No evidence that sleep disturbance after mTBIshould be treated any differently than sleep dysfunction from other causes

• Consider risks for falls and confusion when prescribing medications

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Sleep Agents

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Agents Comments

Alpha‐blocker • Prazosin • See previous mentions

Hypnotics • Eszopiclone• Zaleplon• Zolpidem

• Not indicated for long term use• Sleep walking and short‐term amnesia

reported• Zaleplon preferred if issue is sleep onset

and latency• May cause abnormal dreams

Antidepressants • Trazodone• Amitryptiline• Doxepin• Mirtazapine

• Useful for common comorbid conditions• Headache is a common side effect

Melatonin receptor Agonist

• Ramelteon • Not to be used in combination with fluvoxamine

• Drug interaction with CYP1A2 inhibitors (smoking)

Orexin‐Receptor Antagonist

• Suvorexant • May cause headache• Significant drug interactions

Non‐Pharmacological Therapies

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Potential Interventions

• Persistent Paino Rehabilitation

o Acupuncture

o Exercise

o Education

• Fatigue and Sleepo CBT‐i – Mobile App available

o Exercise

o Education – Sleep Hygiene

• Tinnituso White noise generators

o Relaxation therapies

o Hypnosis

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LIFEARMOR APP• 17 topics for veterans after deployment

• Offers self‐help techniques and tools

• Featureso Education about subject matters

o Self Assessments

o Tools for coping and managing symptoms

o Video Links

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Alcohol and Drugs

Anger Anxiety DepressionFamilies and Friendships

Families with Kids

Life stressMild

Traumatic Brain Injury

Physical InjuryPost

Traumatic Stress

Resilience Sleep

Spirituality Stigma TobaccoWork

Adjustment

Electronic Resources

• Scan for free VA mobile apps to help with insomnia, PTSD and mindfulness!o PTSD Coach (iPhone & Android)

o Mindfulness Coach (iPhone only)

o CPT Coach (iPhone only)

o CBT‐i Coach (iPhone & Android)

• https://mobile.va.gov/appstore/veterans

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Vet Centers

• Provide a broad range of counseling, outreach, and referral services to combat Veterans and their families

• All services are free of cost and are strictly confidentialo Individual and group counseling for Post‐Traumatic Stress Disorder (PTSD)

o Alcohol and drug assessment

o Suicide prevention referrals

• Vet Center Call Center 1‐877‐WAR‐VETS (1.877.927.8387)o The staff is comprised of combat Veterans from several eras and their family members

o Veterans can talk about their military experiences or readjustment issues

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Vet Center National Directory• Website:

https://www.va.gov/directory/guide/vetcenter.asp

• Search for o Centers within radius

o Centers within a state or territory

• Includes address, phone number, link for directions, hours of operation, and key staff members

• Locations in surrounding territories US Territorieso US Virgin Islands

o Puerto Rico

o Guam

o American Samoa

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True or False

• Sleep disturbances that occur as a result of a TBI are unique and should be treated differently than other sleep disturbances

• The most common type of traumatic brain injury is mild

• Traumatic brain injuries are diagnosed based on structural imaging

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TRUE FALSE

TRUE FALSE

TRUE FALSE

Questions?

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presentation post-traumatic stress disorder and...

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